Ambulance ramping affecting St John's service

"Just when you think you've seen it all before, you're faced with something that tugs at your heart strings and challenges you clinically and mentally."

Those are the words of a senior paramedic, who has been caring for the ill and injured for more than a decade.

He's one of 800 paramedics working for St John, which is contracted and funded by the State Government to provide WA's ambulance service.

The non-profit organisation is posting some of its best ever response times, following a major shake-up four years ago.

But record levels of ambulance ramping are threatening to derail the hard work.

Trust rattled

Paramedics have always enjoyed a high level of trust in the community.

But that trust was rattled in 2009 when the ABC's Four Corner's program aired explosive revelations about St John.

Dozens of paramedics came forward claiming St John's failure to properly prioritise emergency calls could have contributed to the deaths of four patients.

A subsequent government inquiry recommended sweeping changes to the organisation.

Since then, St John has introduced a structured call handling system, which has seen the number of calls classed as priority-one jump by almost 50 per cent.

It has also recruited more than 200 extra full-time staff, revamped its complaints system and improved clinical governance.

The government has boosted funding to St John from around $42 million in 2008/9 to an expected $100 million this year.

WA's Auditor General Colin Murphy examined the changes in a report tabled to Parliament recently.

"Our audit reports invariably do have areas that need to be improved but I believe this one is overwhelmingly positive," he said.

"Before, if somebody needed an ambulance there was a concern as to whether they'd actually receive one.

"Now there's a much lower risk that someone who's in desperate need of an ambulance will be classified too low."

St John received 291,000 calls for help in the 2012-13 financial year, an increase of 14 per cent since 2010.

It aims to have an ambulance at the most serious emergencies within 15 minutes, in 90 per cent of all cases.

Despite the rise in demand, the service has achieved or bettered that target in all but one month out of the last 12.

"To improve the service and meet the targets is an achievement but to do so while the demand for ambulance services is going up and with unprecedented levels of ramping is doubly an achievement," Mr Murphy said.

But ambulance ramping is starting to bite.

The risks of ramping

Ramping refers to the practice of ambulance crews waiting outside hospitals to unload patients because there aren't any beds available inside.

They waited for almost 1600 hours last month, double the number for the same period last year.

This winter is tipped to be the worst on record for ramping, and St John CEO Tony Ahern says that's not good news for response targets.

"Response times are simply a product of how many how many ambulances you have spread out across the metropolitan area at the times the call comes in," he said.

"If you have enough ambulances you hit targets, and if you don't have enough you don't hit targets.

"If we're seeing 40 or 50 hours of ramping in a given day, we'll probably still be at, or very close to, our targets but once we see ramping go above those levels then it does impact."

Mr Murphy says it already has.

"July 2012 was the only month St John didn't meet response times, and that's simply because ramping was at unprecedented levels during that time," he said.

"We've identified ramping as one of the issues that seriously needs to be addressed if we're going to maintain those improvements.

"It's a key threat."

Trial and error

For the last two months, ambulances carrying patients with less acute needs have been diverted to a 15-bed overflow ward at the private Hollywood Hospital as part of a new trial.

It's hoped the program will ease the pressure on emergency wards, allow ambulances to get back on the road quicker and help patients avoid lengthy wait times.

The ward runs from 10am to 10pm every day and is staffed by St John paramedics, a nurse and a GP.

So far, more than 270 patients have been cared for in the ward.

Two thirds of those were sent to public hospitals, while the rest were discharged or admitted to private hospitals.

A further 120 were referred to support services such as Silver Chain or Bridge House.

Mr Ahern is pleased with the results and says the idea of diverting patients away from emergency departments has merit.

"I can understand the people working in emergency departments are saying 'hang on, that's not right, we should just have the capacity here to bring them in'," he said.

"But this process plays a role in identifying alternate pathways and it should be incorporated into the system permanently.

"If we we can find ways to apply this same process to a much greater proportion of our non-urgent patients, I believe it can make a difference (to ramping levels)."

The Health Minister Kim Hames is also pleased with the results of the trial but acknowledges it's not an ideal situation.

"We would far rather those patients went to our hospitals to get treated and processed through that system," he said.

"But with the numbers of beds in the system at present not being adequate for the growth in population, we need to find alternate methods to stop people sitting in ambulances ramped outside hospitals.

"Nobody wants to see that."

But emergency physician and former Australian Medical Association WA president Dave Mountain isn't convinced.

"These sort of solutions are so pathetic in the face of how big the problems are, that there's very little bonus to anybody in this," he said.

"I think its wasted money.

"It may improve to a degree the amount of ambulances that can go back on the road but it has no benefits to the patients who are delayed for another five or six hours before they get definitive care."

Solving the problem

So what is the solution to ramping?

The AMA says it's hospital beds, and lots of them.

The Health Minister says he is adding more beds through the Joondalup and Midland Hospital expansions and the Fiona Stanley Hospital will add another 200 beds to the system when it starts coming online in October 2014.

But the AMA says with around 1500 people moving to WA every week, 120 extra beds need to be found every year just to keep up with population growth.

"By the time FHS does come online, all the extra capacity will have already be used up by the growing population," Mr Mountain said.

"We should already be planning the next set of hospitals and the next set of openings."